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Lill' Appendix VI JUN o3 2016 MONITORING SYSTEM CERTIFICATION�� For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information 9 Bldg. Pilot -Flying J #618 Facility Name: Y g. No.: 1501 Site Address: 1501 N Jacktone Rd. City: Ripon Zip: 95366 Facility Contact Person: Manager Make/Model of Monitoring System: TLS 350 Contact Phone No.: ( 209 ) 599-4141 Date of Testing/Servicing: 0 5/ 04 / 2 0 1 6 B. Inventory of Equipment Tested/Certified rhark fha nnnrnnrinfa hmrae fn inefirnfa enarifir anifinmanf 1nenartari/carvilrraA- Tank ID: T5 91 12K Tank ID: T6 Auto Diesel 12K )i7 In -Tank Gauging Probe. Model: 847390-109 x❑ In -Tank Gauging Probe. Model: 847390-109 )CI Annular Space or Vault Sensor. Model: 794380-303 Ko Annular Space or Vault Sensor. Model: 794380-303 >C Piping Sump / Trench Sensor(s). Model: 794380-208 Ka Piping Sump/ Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A )Cl Mechanical Line Leak Detector. Model: yMl LD2000 M7 Mechanical Line Leak Detector. Model: Fx1yD ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A )e Tank Overfill / High -Level Sensor. Model: OPw Flapper x❑ Tank Overfill / High -Level Sensor. Model: OPw Flapper ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Others ecif a ui ment t e and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: D Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pa e 2 . ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 13 Dispenser ID: 14-15 )r] Dispenser Containment Sensor(s). Model: 794380-20e /i7 Dispenser Containment Sensor(s). Model: 794380-208 n Shear Valve(s). 'f7 Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chains . Dispenser ID: 16 Dispenser ID: 19M C Dispenser Containment Sensor(s). Model: 794380-208 )EI Dispenser Containment Sensor(s). Model: 794380-208 JD Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 193 Dispenser ID: 20M U Dispenser Containment Sensor(s). Model: �9a3sazoe C Dispenser Containment Sensor(s). Model: 794380-20e )0 Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): %I System set-up 9 Alarm history report Garcia Technician Name (print): Issac Signature: Certification No.: 842806 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(888 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 0 5 / 04 / 2 0 1 6 Monitoring System Certification Page of 12/07